For speed of communications and cost effectiveness, individuals, businesses, and other organizations frequently exchange electronic data through e-mail, the Internet, and other networks and systems. For example, health-care providers such as medical clinics and hospitals typically communicate over the Internet with insurance companies to determine the eligibility for insurance coverage of patients seeking health care treatment. The insurance companies, which are the final payers of patients' claims for insurance coverage, and the providers may communicate directly, or the insurance companies may use intermediaries for processing information from providers.
FIG. 1 shows a typical operating environment through which providers and payers can communicate over a network, using an intermediary if necessary. Servers 100, 150, 160, 170, and 180 can communicate via a wired or wireless network 130, and wired or wireless links 142, 144, 145, 146, and 148. The servers 100, 150, 160, 170, and 180 may be personal computers or larger computerized systems or combinations of systems. The network 130 may be the Internet, a private LAN (Local Area Network), a wireless network, a TCP/IP (Transmission Control Protocol/Internet Protocol) network, or other communications system, and can comprise multiple elements such as gateways, routers, and switches. Links 142, 144, 145, 146, and 148 use technology appropriate for communications with network 130.
For example, an operator at a hospital at provider server 1 150 can employ a user interface UI 1 310, such as a screen on a computer terminal, to request information about eligibility and benefits data for a patient from the patient's insurance company at payer server 1 170 through the insurance company's user interface UI 3 330. An operator at payer server 1 170 can then employ user interface UI 3 330 to send the requested information to an operator at provider server 1 150 through user interface UI 1 310. Alternately such information can also be exchanged through machine to machine transmission instead of through operator-controlled screens.
Moreover, an insurance company such as the one at payer server 1 170 can use a service on another server, such as server 1 100, as an intermediary for processing provider requests and sending requested information back to providers.
In such a system, additional providers, such as a clinic at provider server 2 160, and payers, such as an insurance company at payer server 2 180, can further communicate information about the insurance coverage for different treatments and different patients.
It is important to note, however, that an insurance company typically has a large amount of different eligibility and benefits data depending on the category of health care provided to a patient. For example, an insurance company may have different eligibility requirements, co-payments, and amounts of coverage for treatments covering psychiatry, neurology, dermatology, and urgent care such as emergency room treatment. Moreover, patients' coverage may change depending on whether they receive treatment from private clinics or from hospitals and on whether the providers are in-network or out-of-network according to an insurance company's plan.
Typically, an insurance company cannot identify the category of coverage associated with a particular provider's request for eligibility and benefits data and sends a collection of all its eligibility and benefits data to the provider. This means that the provider must then manually read through the entire collection of data to identify the specific information that applies to a particular patient's treatment, which is unnecessarily laborious, expensive, and time consuming.
Therefore there is a need for a method and system that provides a more automatic method to supply only that eligibility and benefits data from an insurance company that applies to a particular health care provider's circumstances.